JP2008528958A - Use of cardiac hormones to assess cardiovascular risks associated with the administration of anti-inflammatory agents - Google Patents

Abstract

The present invention relates to the use of cardiac hormones, particularly natriuretic peptides, for diagnosing the cardiovascular risk of a patient who is a candidate for adminitstration of a Cox-2-inhibiting compound, in particular an NSAID, selective Cox-2 inhibitior, or steroid. More particularly, the present invention relates to the use of cardiac hormones, particularly natriuretic peptides, for diagnosing the cardiovascular risk of a patient who is a candidate for administration of a selective Cox-2 inhibitor, comprising the steps of (a) measuring, preferably in vitro, the level of a cardiac hormone, (b) diagnosing the risk of the patient by comparing the measured level to known levels associated with different grades of risk in a patient. The most preferred cardiac hormone in the context of the present invention is NT-proBNP. Furthermore, the present invention relates to a method for diagnosing the risk of a patient to suffer from a cardiovascular complication as a consequence of administration of a Cox-2 inhibiting compound , comprising the steps of (a) measuring the level of a cardiac hormone, (b) diagnosing the risk of the patient by comparing the measured level to known levels associated with different grades of risk in a patient.

Description

  The present invention relates to the use of cardiac hormones to assess a patient's cardiovascular risk associated with the administration of anti-inflammatory agents, particularly NSAIDs (non-steroidal anti-inflammatory agents) or steroids, particularly selective Cox-2 inhibitors.

  One goal in modern medicine is to provide an individual or individualized treatment. These are treatments that take into account the individual needs or risks of the patient. Of particular importance is the presence of cardiovascular risk or cardiovascular complications, especially unrecognized cardiovascular risks or cardiovascular complications.

  Selective Cox-2 inhibitors are commonly used effective anti-inflammatory agents. Compared to many other anti-inflammatory agents, selective Cox-2 inhibitors appear to cause fewer gastrointestinal side effects (eg, gastrointestinal bleeding or ulcers). Thus, for many patients, treatment with selective Cox-2 inhibitors is a selective treatment.

However, it has recently been found that selective Cox-2 inhibitors can cause cardiovascular complications, followed by cardiac decompensation and even death. APPROVE study (Adenomatous Polyp Prevention On Vioxx) was stopped early, followed by rofecoxib (VIOXX ^™ ) (selective Cox-2) due to a 3.9-fold increase in the rate of serious thromboembolic events Only the inhibitor) was recently recovered from the market by the manufacturer (Merck). This study on secondary prevention of colon adenoma included only patients with no recognizable cardiovascular risk. Using 25 mg of rofecoxib was found to be at a higher blood pressure level than placebo, even in the post-initial observation phase. For every 1000 patients treated with 25 mg of rofecoxib compared to placebo (myocardial infarction, stroke), an additional cardiovascular event was found in 16 patients at 18 months of follow-up (Non-Patent Document 1). High cardiovascular risk has also been examined in other studies (VIGOR) and is supported by data from recent meta-analysis (Non-Patent Document 2; Non-Patent Document 3).

Similar cardiovascular side effects, although with a low incidence, other selective cyclooxygenase (COX) -2 inhibitors such as celecoxib (Celebrex ^TM , Pfizer), lumiracoxib (Prexige ^TM , Novartis) and parecoxib (valdecoxib prodrugs) )) Is considered to be within the range of side effects (class effect) (Non-Patent Document 4; Non-Patent Document 5).

  Cardiovascular complications (eg, acute myocardial infarction or stroke) can result in serious health problems and even death. Therefore, many patients who would benefit greatly from treatment with selective Cox-2 inhibitors are not treated because it is unclear whether the treatment can cause cardiovascular complications.

  Cardiovascular problems or risks can remain asymptomatic for extended periods. As a result, it is more difficult to make a reliable diagnosis of the presence of cardiovascular risk than is generally possible, and it is easy to make mistakes. In particular, general practitioners and non-cardiologists are often unable to identify previously unidentified cardiovascular problems.

  Techniques in the art can only exclude patients with a known history of cardiovascular symptoms or heart disease or hypertension by treatment with selective Cox-2 inhibitors.

  Such risk management is inadequate so that asymptomatic patients can also develop cardiovascular complications due to unidentified predisposition (eg, the presence of arterial plaque). As noted above, only patients with no appreciable cardiovascular risk were included in the APPROVE study, but treatment of some patients resulted in cardiovascular complications.

  The prior art does not suggest any way to diagnose the risk of cardiovascular complications associated with treatment with anti-inflammatory agents (especially selective Cox-2 inhibitors). In particular, there are no references on how to examine patients who do not have a known history of cardiovascular complications.

  This is not only true for selective Cox-2 inhibitors, but also inhibitors of other types of anti-inflammatory agents that can cause cardiovascular complications (eg, Cox-2 and other targets such as Cox-1) This also applies to Examples of such other types of anti-inflammatory agents include non-selective Cox-2 inhibitors (compounds that inhibit Cox-1 and Cox-2). Even though the risk of developing cardiovascular complications is not as high as that of selective Cox-2 inhibitors, possible cardiovascular complications may be considered.

  For example, cardiovascular side effects from other anti-inflammatory agents (especially other NSAIDs or steroids) are also possible.

Therefore, there is a need for a method or means of identifying a patient's risk before the patient is treated with an anti-inflammatory agent, particularly an NSAID or steroid, especially a selective Cox-2 inhibitor. In particular, there is a need to provide suitable diagnostic means. In particular, there is a need for diagnostic tools that allow identification of the risk of patients who do not have a history of cardiovascular risk or complications or a known history. The diagnostic means should also be reliable and suitable for use by general practitioners and non-cardiologists.
Topol EJ. Failing the public health--rofecoxib, Merck, and the FDA.N Engl J Med 2004; 351: 1707-9 Bombardier C, Laine L, Reicin A, Shapiro D, Burgos-Vargas R, Davis B, Day R, Ferraz MB, Hawkey CJ, Hochberg MC, Kvien TK, Schnitzer TJ; VIGOR Study Group. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis.VIGOR Study Group.N Engl J Med 2000; 343: 1520-8 Jueni P, Nartey L, Reichenbach S, Sterchi R, Dieppe PA, Egger M. Risk of cardiovascular events and rofecoxib: cumulative meta-analysis. Lancet 2004; online ahead Fitzgerald GA. Coxibs and cardiovascular disease.N Engl J Med 2004; 351: 1709-1711. Mukherjee D, Nissen SE, Topol EJ.Risk of cardio cardiovascular events associated with selective Cox-2 Inhibitors.JAMA 2001; 286: 954-959.

The object of the present invention is a method for diagnosing the risk of a patient suffering from cardiovascular complications as a result of administration of an anti-inflammatory agent (especially an NSAID, steroid or selective Cox-2 inhibitor) comprising:
a) measuring cardiac hormone levels;
b) achieved by a method comprising diagnosing the patient's risk by comparing the measured level to a known level associated with various degrees of risk of the patient.

Furthermore, an object of the present invention is a method for diagnosing cardiovascular risk in a patient who is to be administered a compound having Cox-2 inhibitory properties,
a) measuring the level of cardiac hormone, preferably in vitro;
b) achieved by a method comprising diagnosing the patient's risk by comparing the measured level to a known level associated with various degrees of risk of the patient.

  A compound having Cox-2 inhibitory properties (also referred to as a Cox-2 inhibitor) can also be a compound having anti-inflammatory properties (eg, can be a steroid or NSAID). Most preferably, the compound is a selective Cox-2 inhibitor.

Another object of the present invention is a method for determining a feasible treatment for a patient using a compound having Cox-2 inhibitory properties,
a) measuring cardiac hormone levels in the patient, preferably in vitro;
b) comparing the measured level to a known level associated with various degrees of risk of the patient;
c) optionally initiating examination of the patient by a cardiologist;
d) optionally recommends starting or stopping treatment, taking into account the patient's test results by a cardiologist,
Is achieved by a method comprising:

  A compound having Cox-2 inhibitory properties (also referred to as a Cox-2 inhibitor) can also be a compound having anti-inflammatory properties (eg, a steroid or NSAID). More preferably, the compound is a selective Cox-2 inhibitor.

  As noted above, it is apparent that the method is preferably performed prior to administering the subject compound.

  The method can also include collecting a body fluid or tissue sample from the patient. In the present invention, such body fluid or tissue sample collection may preferably be performed by non-medical staff (ie, an untrained person required to perform medical practice). This is especially true when the body sample is blood.

  It is also an object of the present invention to diagnose a patient's heart hormone (especially natriuretic peptide) in order to diagnose the cardiovascular risk of the patient who is the subject of administration (especially future administration) of a compound having Cox-2 inhibitory properties. ) Is preferably achieved by using a diagnostic method for measuring in vitro. Preferably, the level is measured in a patient fluid or tissue sample.

  Also, a compound having Cox-2 inhibitory properties (also referred to as a Cox-2 inhibitor) can be a compound having anti-inflammatory properties (eg, a steroid or NSAID). Most preferably, the compound is a selective Cox-2 inhibitor.

  The present invention relates to patients who are about to receive drugs with compounds with Cox-2 inhibitory properties (especially selective Cox-2 inhibitors), with regard to the risk of these patients developing cardiovascular complications with the drugs. Provide simple and inexpensive methods and means for screening. Such agents may include anti-inflammatory agents or compounds with Cox-2 inhibitory properties, in particular NSAIDs, steroids, selective Cox-2 inhibitors or combinations thereof. For example, such drug treatment can include a combination treatment with a steroid and a selective Cox-2 inhibitor, or a combination treatment with a selective Cox-2 inhibitor and another NSAID (see Example 5). The present invention also provides cardiac hormone levels that indicate the presence or severity of cardiovascular risk in patients who exhibit obvious symptoms of cardiovascular complications and / or cardiovascular disease, or in patients who do not exhibit such symptoms To do.

  Patients with a history of cardiovascular disease (myocardial infarction, unstable angina, coronary artery disease, heart failure, CABG (coronary artery bypass graft), stroke) or underlying inflammatory disease (eg, chronic polyarthritis, degenerative joints) Patients with rheumatoid arthritis, rheumatoid arthritis or other rheumatoid disorders) are more likely to develop cardiovascular complications. In patients with rheumatoid arthritis, cardiovascular mortality is particularly high for a variety of reasons.

  Furthermore, individuals with a history of cardiovascular disease (ie, individuals with stable angina (SAP) and individuals with acute coronary syndrome (ACS)) are likely to develop cardiovascular complications. It is done. ACS patients may exhibit unstable angina (UAP), otherwise these individuals may already have myocardial infarction (MI). MI may be ST-elevated MI or non-ST-elevated MI. Following the onset of MI, left ventricular dysfunction (LVD) may develop. Finally, LVD patients develop congestive heart failure (CHF) with a mortality rate of approximately 15%.

  Symptoms of cardiovascular disease include, for example, new Q waves or leg blocks, signs of non-fatal stroke, the onset or worsening of heart failure indicated by the onset of edema or deterioration of existing edema of the lower limbs, and aural sound Or pulmonary congestion, new onset of arterial hypertension or exacerbation of existing arterial hypertension, and venous thrombosis.

  Symptoms of cardiovascular disease are classified using a functional classification system by the New York Heart Association (NYHA). Class I patients do not show any overt symptoms of cardiovascular disease. Physical activity is not restricted, and normal physical activity does not cause excessive fatigue, palpitation, or dyspnea (shortening of breathing). Class II patients are subject to slight restrictions on physical activity. The patient is comfortable at rest, but with normal physical activity, fatigue, palpitation, or difficulty breathing. Class III patients are significantly restricted in physical activity. Patients are comfortable at rest, but physical activity that is lighter than normal activity causes fatigue, palpitation, or dyspnea. Class IV patients cannot perform any physical activity without discomfort. The patient exhibits symptoms of heart failure at rest, and discomfort increases when any physical activity is performed.

  In the present invention, the cardiovascular complications in the present invention may cause symptoms, particularly NYHA class II-IV symptoms, and more particularly NYHA class III-IV symptoms.

  The present invention is particularly advantageous for identifying patients at risk who do not exhibit any symptoms of existing cardiovascular disease, risk or complications. The present invention is also useful for confirming or monitoring a patient's risk status for symptoms of cardiovascular disease.

  Patients with underlying cardiovascular disease are inherently able to inhibit Cox-2 inhibitory activity without measuring cardio-hormonal levels when the patient exhibits symptoms that can stratify the risk of suffering from the patient's cardiovascular complications Are excluded from treatment with compounds having a, particularly selective Cox2 inhibitors. This exclusion is made especially for patients with ischemic coronary heart disease, patients who have had a stroke, or patients classified as NYHA class III-IV. These patients should not be administered compounds with Cox-2 inhibitory activity, in particular selective Cox2 inhibitors, but by measuring cardiac hormones according to the present invention, individual risk stabilization, Cox-2 inhibition Allows initiation of treatment of a patient with a compound having activity, in particular a selective Cox2 inhibitor, and / or monitoring of treatment (if administration is required or highly recommended).

  Symptoms do not clearly classify patients (and therefore cannot decide to exclude patients (both men and women) from treatment with compounds with Cox-2 inhibitory activity) or patients have cardiovascular complications Assessment of an individual's risk can be performed after measuring heart hormones if it does not indicate a recognizable risk of suffering from the disease. Individual assessments are particularly performed in patients who belong to a group at risk (ie, a history of a particular disease or a group with a life history known to increase the likelihood of suffering from cardiovascular complications). Is called.

  Assessment of individual risk is particularly beneficial in the following patient groups: patients classified as NYHA class I-II, patients with diabetes, hyperlipidemia, or hypertonie, smokers, and Patients who are elderly (eg, 55 years or older).

  The use of heart hormones and natriuretic peptides as molecular or biochemical markers is known per se. WO 02/089655 proposes measuring brain natriuretic peptide (BNP) to diagnose various myocardial infarctions. WO 02/083913 proposes using BNP to predict short-term morbidity or mortality in patients with non-ST elevation acute coronary syndrome. A previously unpublished European application (EP 1 577 673 A1) proposes the use of natriuretic peptides to diagnose the risk of patients suffering from cardiovascular complications due to increased intravascular volume.

  The present invention is particularly useful for general practitioners, specialists, and specialist wards, specialist departments, or specialist clinics that do not have the means to frequently use large-scale cardiology studies by cardiologists. The present invention exposes such non-cardiologists to cardiovascular risks associated with the administration of Cox inhibitors or anti-inflammatory agents, particularly NSAIDs, steroids or selective Cox-2 inhibitors, from among multiple patients. A simple and reliable method and means for screening and identifying existing patients. Preferably, the decision regarding the continuation or initiation of treatment with Cox-2 inhibitors, in particular NSAIDs, steroids or selective Cox-2 inhibitors is made by the physician. More preferably, the decision regarding continuation or initiation of treatment with Cox-2 inhibitors, in particular NSAIDs, steroids or selective Cox-2 inhibitors is made by a cardiologist or after consultation with a cardiologist The This is especially true when high levels of cardiac hormones or natriuretic peptides are measured. If the patient is diagnosed with no cardiovascular risk, decisions regarding continuation or initiation of treatment with Cox-2 inhibitory compounds, particularly NSAIDs, steroids, or selective Cox-2 inhibitors, may be made by non-cardiologists. It can be done by a doctor.

  The present invention utilizes specific biochemical or molecular markers. The terms “biochemical marker” and “molecular marker” are known to those skilled in the art. Specifically, a biochemical marker or molecular marker is specifically expressed (ie, up-regulated or down-regulated in the presence or absence of a particular condition, disease, or complication. Gene expression product). Usually, molecular markers are defined as nucleic acids (such as mRNA) and biochemical markers are proteins or peptides. A suitable biochemical or molecular marker can indicate the presence or absence of a condition, disease, risk or complication, depending on its level, thereby allowing diagnosis.

  The present invention particularly utilizes natriuretic peptides as biochemical markers. It should be noted that natriuretic peptides can be secreted in response to ischemia. In the present invention, it is also conceivable to use any combination of natriuretic peptides as a biochemical marker.

  Natriuretic peptides used in the present invention include ANP-type peptides and BNP-type peptides, and mutants thereof (for example, Bonow, RO (1996), New insights into the cardiac natriuretic peptides. Circulation 93: 1946-1950 See).

  ANP-type peptides include pre-proANP, proANP, NT-proANP, and ANP.

  BNP-type peptides include pre-proBNP, proBNP, NT-proBNP, and BNP.

  The prepropeptide (134 amino acids in the case of preproBNP) contains a short signal peptide that is cleaved by the enzyme to release the propeptide (108 amino acids in the case of proBNP). This propeptide is further cleaved into an N-terminal propeptide (NT-propeptide, 76 amino acids in the case of NT-proBNP) and an active hormone (32 amino acids in the case of BNP, 28 amino acids in the case of ANP). The

Preferred natriuretic peptides according to the invention are NT-proANP, ANP, NT-proBNP, BNP and variants thereof. ANP and BNP are active hormones and have a shorter half-life than their respective inactive counterparts (NT-proANP and NT-proBNP). BNP is metabolized in the blood, while NT-proBNP circulates in the blood as an untreated molecule and is removed by the kidneys. The in-vivo half-life of NT-proBNP is 20 minutes (Smith MW, Espiner EA, Yandle TG, Charles CJ, Richards AM.Delayed metabolism of human brain natriuretic peptide receptor resistance to neutral endopeptidase J Endocrinol. 2000; 167: 239-46.)) 120 minutes longer.
NT-proBNP makes pre-analysis more steady and simplifies sample transport to the central laboratory (Mueller T, Gegenhuber A, Dieplinger B, Poelz W, Haltmayer M, Long-term stability of endogenous B -type natriuretic peptide (BNP) and amino terminal proBNP (NT-proBNP) in frozen plasma samples, Clin Chem Lab Med, 2004, 42: 942-4). Blood samples can be stored for several days at room temperature, or mailed or shipped without loss of recovery. In contrast, at least 20% loss of concentration occurs when BNP is stored at room temperature or 4 ° C. for 48 hours (Mueller T, Gegenhuber A, et al, Clin Chem Lab Med 2004; 42: 942-4, supra. ; Wu AH, Packer M, Smith A, Bijou R, Fink D, Mair J, Wallentin L, Johnston N, Feldcamp CS, Haverstick DM, Ahnadi CE, Grant A, Despres N, Bluestein B, Ghani F, Analytical and clinical evaluation of the Bayer ADVIA Centaur automated B-type natriuretic peptide assay in patients with heart failure: a multisite study, Clin Chem 2004, 50: 867-73).

  Thus, depending on the course or characteristics of interest, measurement in the active form of natriuretic peptide may be advantageous or measurement in the inactive form may be advantageous. The most preferred natriuretic peptide in the present invention is NT-proBNP and variants thereof.

As used herein, the term “variant” relates to peptides that are substantially similar to the peptides described above. The term “substantially similar” is well known to those skilled in the art. Specifically, a variant may be an isoform or allele that exhibits an amino acid exchange when compared to the amino acid sequence of the most common peptide isoform in the human population. Preferably, such substantially similar peptides are at least 80%, preferably at least 85%, more preferably at least 90%, most preferably at least 95% relative to the most common isoform of the peptide. Has sequence similarity. Proteolytic degradation products still recognized by the diagnostic means of the present invention or by ligands for the respective full-length peptides are also substantially similar peptides.

  The term “variant” also relates to post-translationally modified peptides, such as glycosylated peptides. Peptides that have been modified after sampling, for example by the addition of a label, in particular by the covalent or non-covalent attachment of radioactive or fluorescent labels to the peptide, are also “variants”.

  Other embodiments of the invention include combining various heart hormones and measuring simultaneously or non-simultaneously. For example, by measuring various cardiac hormones, important additional information can be obtained, for example, information regarding the course of progressive cardiovascular complications. Therefore, the present invention also relates to measuring both ANP-type peptides or variants thereof and BNP-type peptides or variants thereof.

For those skilled in the art, the term “diagnosis” is known. Diagnosis is understood as recognizing a particular medical condition, disease, complication, or risk. Diagnosis is also understood as detecting or measuring the presence of a particular medical condition, disease, complication, or risk. In the present invention, diagnosis includes monitoring, confirmation, subclassification, and prediction of related diseases, complications or risks. Monitoring relates to understanding the trends in risk or complications already diagnosed in order to analyze the increase or decrease in risk or the effect of treatment on the increase or decrease in risk. Confirmation relates to enhancing or substantiating a diagnosis already made using other indicators or markers. Subclassification relates to identifying the diagnosis in more detail according to various subclasses of the risk of the diagnosed disease, for example making the identification according to a high or very high risk. Prediction relates to predicting cardiovascular risk before other symptoms or markers become obvious or change significantly.
An individual suffering from cardiovascular disease can be an individual suffering from stable angina (SAP) and can also be an individual suffering from acute coronary syndrome (ACS). ACS patients may exhibit unstable angina (UAP), otherwise these individuals may already have myocardial infarction (MI). MI may be ST-elevated MI or non-ST-elevated MI. Following the onset of MI, left ventricular dysfunction (LVD) may develop. Finally, LVD patients develop congestive heart failure (CHF) with a mortality rate of approximately 15%.

  Furthermore, an individual suffering from cardiovascular disease may be an individual suffering from a stroke. The term “stroke” refers to a cerebrovascular event in which blood flow to a small or large part of the brain is blocked by bleeding into the brain or thrombus in the cerebral artery. Stroke can temporarily cause loss of consciousness or paralysis. The stroke in this case is called “apoplectic stroke”.

The individual may exhibit clinical symptoms (eg, dyspnea, chest pain, see NYHA classification below), and the individual may be asymptomatic. The present invention is particularly effective in identifying patients at risk of not exhibiting symptoms of an existing cardiovascular disease, risk or complication, but other settings such as patients exhibiting symptoms of cardiovascular disease It is also useful for confirming or monitoring the risk status of
The term “cardiovascular risk” relates to the risk of developing cardiovascular complications.
The present invention relates to “cardiovascular complications” that develop upon administration of anti-inflammatory agents or Cox-2 inhibitors, particularly NSAIDs, steroids, or selective Cox-2 inhibitors. Cardiovascular complications are also known as “cardiovascular events”. In the following, the term “cardiovascular complication” will be used exclusively or mostly.

  The term “cardiovascular complication” is known to those skilled in the art. Thus, in the present invention, the term “cardiovascular complication” relates to any kind of cardiovascular complication or heart failure (especially acute heart failure) known to those skilled in the art, and in particular the term refers to arterial thrombus or arterial thrombus development. Refers to related complications. Arterial thrombosis can cause coronary insufficiency syndrome (eg, acute myocardial infarction or stroke).

  In particular, “cardiovascular complications” relate to complications in the arterial system (eg, ACS, UAP, MI, ST-elevated MI, non-ST-elevated MI or stroke).

More specifically, “cardiovascular complications” refers to MI, ST-elevated MI, non-ST-elevated MI or stroke.
Symptoms of cardiovascular disease include, for example, new Q waves or leg blocks, signs of non-fatal stroke, the onset or worsening of heart failure indicated by the onset of edema or deterioration of existing edema of the lower limbs, and aural sound Or pulmonary congestion, new onset of arterial hypertension or exacerbation of existing arterial hypertension, and venous thrombosis.

  Symptoms of cardiovascular disease are classified using a functional classification system by the New York Heart Association (NYHA). Class I patients do not show any overt symptoms of cardiovascular disease. Physical activity is not restricted, and normal physical activity does not cause excessive fatigue, palpitation, or dyspnea (shortening of breathing). Class II patients are subject to slight restrictions on physical activity. The patient is comfortable at rest, but with normal physical activity, fatigue, palpitation, or difficulty breathing. Class III patients are significantly restricted in physical activity. Patients are comfortable at rest, but physical activity that is lighter than normal activity causes fatigue, palpitation, or dyspnea. Class IV patients cannot perform any physical activity without discomfort. The patient exhibits symptoms of heart failure at rest, and discomfort increases when any physical activity is performed.

  In the present invention, the cardiovascular complications in the present invention may cause symptoms, particularly NYHA class II-IV symptoms, and more particularly NYHA class III-IV symptoms.

  “Left ventricular ejection fraction” (LVEF), also known as “ejection rate”, can be another characteristic of cardiovascular complications or dysfunction. People with a healthy heart usually have healthy LVEF, which is usually described as over 50%. Most people with symptomatic systolic heart disease usually have LVEF of 40% or less.

Cardiovascular complications (eg, MI) may be accompanied by LVEF of 40% or less.
Heart failure may be “compensatory” or “decompensated”. Compensatory means that the normal oxygen demand in the body can still be met, while decompensated means that the normal oxygen demand in the body is not already met.

  In the present invention, “diagnosing cardiovascular risk” includes diagnosing (ie, recognizing) cardiovascular risk, and monitoring the increase or decrease in existing or known cardiovascular risk.

  According to the present invention, the term “patient” relates to a healthy individual, a clearly healthy individual, or in particular an individual suffering from a disease. The patient may be male or female because the present invention is suitable for diagnosing both. Specifically, the patient has or is treated with rheumatoid arthritis, rheumatoid arthritis (chronic polyarthritis), osteoarthritis, psoriatic arthritis, spondyloarthropathy, or other inflammatory diseases or osteoarthritis Is receiving. The patient may also have ulcers or cancer. In this context, the above mentioned diseases are considered part of treatment by administration of compounds with Cox-2 inhibitory properties (eg anti-inflammatory agents), in particular NSAIDs, steroids or selective Cox-2 inhibitors It should be noted that it is a disease. Even more particularly, the patient does not have any known history of cardiovascular risk or complications and / or shows no or only signs of cardiovascular risk or complications and / or heart Not being treated for vascular risk or complications. However, healthy individuals who have no signs or history of cardiovascular risk or complications are also considered patients in the present invention.

  Preferably, the patient is being treated or is about to be treated with an anti-inflammatory agent. Such a patient is understood as a “subject” of treatment with the drug. More preferably, the patient is being treated or is about to be treated with a selective Cox-2 inhibitor. Such patients are understood as “subjects” of treatment with selective Cox-2 inhibitors. Of course, treatment with each of the drugs or selective Cox-2 inhibitors should generally be considered a reasonable treatment option.

  Understand what cardiovascular complications are considered “as a result” of administration of anti-inflammatory agents or Cox-2 inhibitors, in particular NSAIDs, steroids or selective Cox-2 inhibitors, under what circumstances Known to the public. It should be recognized that it may not be possible or necessary to establish a causal relationship clearly. If a sufficiently high probability is established that cardiovascular complications are caused or caused by administration of anti-inflammatory agents or Cox-2 inhibitors, particularly NSAIDs, steroids, or selective Cox-2 inhibitors May be sufficient. For example, the APPROVE study showed an almost 4-fold increase in cardiovascular complications between the study and placebo groups. In the present invention, it will be appreciated that cardiovascular complications in patients treated with selective Cox-2 inhibitors have also been caused by treatment. Thus, the present invention also relates to diagnosing the risk of suffering cardiovascular complications following administration of anti-inflammatory agents, Cox-2 inhibitors, NSAIDs or selective Cox-2 inhibitors.

  Furthermore, those skilled in the art are familiar with methods or signs that indicate causality. For example, the temporal relationship between administration of a drug and signs of cardiovascular complications always indicates that such drug is the cause of the complication or “caused” the complication. For example, an increase in the number of cardiovascular complications in the APPROVE trial becomes apparent after 18 months of treatment. In another example, if the severity of a cardiovascular complication is related to the amount of drug administered, it can be causal. For example, lesions in an echocardiogram or electrocardiogram may be improved if treatment with the drug is discontinued. In certain instances, the level of one or more heart hormones can be monitored before and during administration of the anti-inflammatory agent. If the level of cardiac hormone increases when starting treatment with the drug and decreases when such treatment is discontinued, it indicates that the drug results in increased cardiovascular risk. Similarly, if the level of cardiac hormone is related to the dose of the drug, this also indicates that the drug results in an increased cardiovascular risk. Cardiovascular complications appearing under such circumstances may have been caused by drug administration. This is even more pronounced when drug administration increases the level of heart hormone abnormally high compared to other patients, or a slight increase in dose results in an abnormally rapid increase in the level of heart hormone. there is a possibility.

Anti-inflammatory agents are known to those skilled in the art. In particular, such agents include non-steroidal anti-rheumatic agents (non-steroidal anti-inflammatory agents, also known as NSAIDs), Cox-2 inhibitors, corticosteroids and TNF inhibitors.
Examples of anti-inflammatory agents include: alclofenac; alcromethasone dipropionate; algestone acetonide; alpha amylase; Amcinafal; amcinafide; amphenafide; amfenac sodium; amiprilose hydrochloride; anakinra; anirolac; Anitrazafen; Apazone; Balsalazide disodium; Bendazac; Benoxaprofen; Benzidamine hydrochloride; Bromelain; Broperamole; Budesonide; Carprofen; Cycloprofen; Cintazone; Cliprofen ); Clobetasol propionate; clobetasone butyrate; Clopirac; cloticasone propionate (Cloticasone Propionate); cormethasone acetate (Cormethasone Acetate); colt Xelone; Celecoxib; Rofecoxib (VIOXX); Etricoxib; Valdecoxib; Parecoxib; Diflunisal; Difluprednate; Diphthalone; Dimethylsulfoxide; Drocinonide; Endrysone; Enlimomab; Enlimomab; Enolicam Sodium; Epirizol; ); Fenbufen; Fenclofenac; Fenclorac; Fendosal; Fenpipalone; Fentiazac; Flazalone; Fluazacort; Fluazacort; Flufenamic acid; Flumisol; Flunisolide acetate; Flunixin; Flunixin meglumine; Fluocortin Butyl; Fluocortin Butyl; Fluretofen; fluticasone propionate; Furaprofen; flobfen; halcinonide; halobetasol propionate; halopredone acetate; ibufenac; ibuprofen; ibuprofen aluminum; ibuprofen piconol; ilonidap Indoprofen; Indoxole; Intrazole; Isoflupred acetate ; Isokusepakku (Isoxepac); isoxicam; ketoprofen; hydrochloride lofemizole (Lofemizole Hydrochloride); Lornoxicam; loteprednol etabonate; meclofenamate sodium; meclofenamic acid; butyric acid Mekurorizon (Meclorisone Dibutyrate); mefenamic acid; meloxicam (Mobic ^TM); mesalamine; Mesekurazon Strepanoic acid methylprednisolone; Morniflumate; Nabumetone; Naproxen; Naproxen sodium; Naproxol; Naproxol; Nimazone; Orsalazine sodium; Orgothein; Orpanoxin; Oxaprozin; Oxyfenbutazone hydrochloride (Paranyline Hydrochloride); sodium pentosan polysulfate; phenbutazone sodium glycerate perphenidone; piroxicam; piroxicam cinnamate; piroxicam olamine; pirprofen; prednazate; prifelone; prodolic acid; proqualic acid; proquazone; proxazole; Proxazole Citrate; Rimexolone; Romazarit; Sarcolex; Salnacedin; Salsalace; Salicylic acid; Sanguinarium Chloride; Seclazone; Sulindac; Suprofen; Talmetacin; Talniflumate; Talosalate; Tebufelone; Tenidap; Tenidap Natri Teoxicam; Tesicam; Tesimide; Tetrydamine; Tiopinac; Thixocortol pivalate; Tolmetine; Tolmetine sodium; Triclonide; Triflumidate; Triflumidate; Zidometacin); and Zomepirac sodium; Etanercept; Lenercept; Infliximab; Cortisone; Fluocortron; Hydrocortisone; Methylprednisolone; Prednisolone; Prednisone and Prednylidene.

  In some cases, measuring the cardiac hormone or natriuretic peptide, eg, NT-proBNP, prior to administering any of the above compounds is included in the present invention.

The term “non-steroidal anti-rheumatic agent” (also called non-steroidal anti-inflammatory drug or NSAID) is known to those skilled in the art. NSAIDs inhibit cyclooxygenase (also known as prostaglandin H synthetase). Cyclooxygenase the reaction from arachidonic acid to prostaglandin H _{2 (cyclic} endoperoxide) catalyzes prostaglandin H _{2 (also} known as prostacyclin) prostaglandin I _2, thromboxane A _2, and It is a precursor of other prostaglandins. Prostaglandins play an important role in pain, heat, and inflammatory responses. There are two isoforms of cyclooxygenase, Cox-1 and Cox-2. The Cox-2 gene is an immediate gene and is induced under conditions of tissue damage, pain response, or inflammatory response. Thus, NSAIDs include Cox-1 inhibitors and Cox-2 inhibitors. NSAIDs may inhibit both isoforms, or may be selective for one isoform (ie, in therapeutic amounts they inhibit only one of the two isoforms).

  Examples of non-specific NSAIDs include ibuprofen; flurbiprofen; naproxen; flufenamic acid; mefenamic acid; piroxicam; diclofenac; Phenbutazone Sodium Glycerate;

  The selective Cox-2 inhibitors used in the present invention inhibit Cox-2 expression or, preferably, enzyme function under therapeutic conditions, but significantly inhibit Cox-1 expression or, preferably, enzyme function. It is a compound that does not. Examples of selective Cox-2 inhibitors include coxib (eg, celecoxib, rofecoxib, etlicoxib, valdecoxib, parecoxib (prodrug of valdecoxib), lumiracoxib), meclofenamic acid, sulindac sulfide, diclofenac, nimesulide, meloxicam, S 98 , L-745337, DFP (3- (2-propyloxy) -4- (4-methylsulfonylphenyl) -5,5 dimethylfuranone). The last three compounds are described in Warner, T.D. et al., 1999.

The enzymatic function of the two cyclooxygenases can be measured by methods known in the art, including appropriate in vivo or in vitro tests. A typical marker for Cox-1 enzyme function is the production of thromboxane A ₂ , while a typical marker for Cox-2 enzyme function is a prostaglandin (eg, prostaglandin E ₂ from macrophages). Is the generation of

  Examples of suitable test systems have been published (eg Warner, TD, Giuliano, F., Vojnovic, I. et al. (1999), Nonsteroid drug selectivities for cyclo-oxygenase-1 rather than cyclo-oxygenase-2 are associated with human gastrointestinal toxicity: A full in vitro analysis, Proceedings of the National Academy of Sciences USA, Vol. 96, pages 7563-7568, related corrections are published in Vol. 96 (17), page 9966d). This assay will be referred to as the William Harvey modified assay. This assay is described in detail in Warner, T.D., et al., Pages 7563-4, the description of which is expressly incorporated herein by reference.

  A selective Cox-2 inhibitor according to the present invention preferably has a Cox-2 selectivity greater than 5 fold when following a William Harvey modified assay, more preferably when following a William Harvey modified assay. , With Cox-2 selectivity greater than 50 times (see Warner, TD et al., FIG. 3 on page 7567).

  Alternatively, a selective Cox-2 inhibitor according to the invention is preferably more selective than diclofenac for Cox-2, more preferably more selective than Nimesulide for Cox-2, and even more preferably Cox under therapeutic conditions. -2 is at least as selective as celecoxib.

In another preferred embodiment, the present invention relates to methods and means for diagnosing cardiovascular risk in patients who are administered “coxib”. Examples of coxibs include celecoxib (Celebrex ^™ , Pfizer), rofecoxib (Biox ^™ , Merck), etoroxib, valdecoxib, parecoxib (prodrug of valdecoxib), and lumiracoxib (Plexidi ^™ , Novartis). Other similar compounds are also encompassed within the scope of the invention, some of which are in the process of development and testing.

The pathological mechanisms currently under discussion for unwanted cardiovascular side effects of selective Cox-2 inhibitors are the following: inhibition of prostaglandin I ₂ (PGI ₂ ) formation is the development of the above cardiovascular events It is thought to be the main cause of PGI ₂ results in inhibition of platelet aggregation, vasodilation and inhibition of smooth muscle cell proliferation in vitro.

On the other hand, thromboxane A ₂ (the most important COX-1 product of platelets) results in platelet aggregation, vasoconstriction and vascular proliferation. When the maintained balance between PGI ₂ and thromboxane A ₂ is broken, it is thought to promote the activation of blood clotting in the blood vessels, increase blood pressure, and accelerate atherosclerosis.

Thus, in a preferred embodiment, the present invention also relates to the use of a cardiac hormone to assess a patient's cardiovascular risk by administration of an anti-inflammatory agent, wherein the cardiovascular risk comprises Cox-1 and Cox-2 inhibition. Disturb the preserved balance between and / or disturb prostaglandin metabolism and / or disturb the preserved balance between PGI ₂ and thromboxane A ₂ , more particularly PGI ₂ Caused by inhibition of formation. The present invention is also for assessing a patient's cardiovascular risk (promoting intravascular thrombosis and / or causing an increase in blood pressure and / or accelerating atherosclerosis) by administration of an anti-inflammatory agent Regarding the use of heart hormones. More preferably, the present invention relates to the use of cardiac hormones to assess the risk of suffering from cardiovascular complications, where risk is due to increased blood volume and volume overload. Not relevant.

  In the present invention, the term “steroid” is used as an abbreviation for “corticosteroid”. It is generally thought that corticosteroids exert their anti-inflammatory activity by affecting prostaglandin metabolism. Examples of corticosteroids according to the present invention include cortisone; fluocortron; hydrocortisone; methylprednisolone; prednisolone; prednisone;

TNF inhibitors are also used as anti-inflammatory agents, particularly in patients with rheumatoid arthritis (increased concentrations of TNF-α were found in patients with rheumatoid arthritis). In addition, inhibition of TNF-α reduces the formation of IL-1 and IL-6. Examples of TNF inhibitors are etanercept, Lenercept (analogon of etanercept), infliximab, and D2E7 (fully humanized monoclonal antibody against TNF-α).
In another preferred embodiment, the present invention provides (a) an inflammation marker, (b) an endothelial function marker, (c) an ischemic marker, (d) a platelet activation marker, (e) an atherosclerosis activation marker, And (f) an activation marker for intravascular coagulation, which additionally relates to measuring the level of at least one marker selected from the group consisting of.

  Measuring additional markers can increase diagnostic selectivity and specificity. It can also help to confirm an established diagnosis by measuring the level of natriuretic peptide.

  Inflammatory markers according to the present invention include any marker that indicates an inflammatory process, particularly a vascular inflammatory process or an arterial inflammatory process. In particular, the inflammatory marker according to the present invention comprises an inflammatory activation cytokine. Examples of inflammation markers include interferon (e.g., interferon γ), interleukin (e.g., IL-1, IL-6, IL-8), tumor necrosis factor (TNF) α), CRP (C-reactive protein), Contains hsCRP (sensitive C-reactive protein).

  Endothelial function markers according to the present invention include any marker that indicates an endovascular repair process, including, for example, cytokines associated with such processes. Examples of such markers include selectins (eg, E-selectin, P-selectin), ICAM-1 (intracellular cell adhesion molecule-1), VCAM-1 (vascular cell adhesion molecule-1), PDGF (platelet Derived growth factors), TGF-α, TGF-β, catecholamines, prostaglandins, angiotensin, endothelin, and NO (nitrogen monoxide). Although already mentioned as inflammatory markers, TNF-α, TNF-β, and IL-1 can also be considered to belong to the group of endothelial function markers.

  Ischemic markers according to the present invention include any marker that indicates insufficient oxygen supply resulting in ischemia. In particular, insufficient oxygen supply is local and the resulting ischemia is also local. Such local ischemia can be caused by an arterial thrombus that restricts blood flow to the target tissue of the affected artery. Examples of ischemic markers include ischemic modified albumin (IMA) and sensitive troponins (eg, TnI and TnT).

  Platelet activation markers according to the present invention include any marker that exhibits platelet activation or aggregation. A preferred marker is soluble CD40 ligand (sCD40L). It should be understood that platelet activation or platelet aggregation can also be measured by analysis of platelet rich plasma samples. After sampling, an attractant is added and the time course of platelet aggregation is measured by the decrease in turbidity. Many small platelets aggregate into large agglomerates, thereby reducing light dispersion and reducing turbidity. The attractant can be any substance deemed appropriate by those skilled in the art (eg, adenosine diphosphate (ADP), serotonin, collagen, protease, or ristocetine). Diagnosis can be made by comparing the measurement results with the results of the same experiment in a control sample or control group. Such a test can therefore consider a marker according to the invention.

  Atherosclerosis activation markers according to the present invention include any marker that indicates the progression of atherosclerosis. An example of an atherosclerosis activation marker is lipoprotein-related phospholipase A2 (Lp-PLA2).

  Examples of activation markers for intravascular coagulation include fibrinogen degradation products, D-dimer and plasminogen activator inhibitors.

  The diagnosis according to the present invention is preferably performed using a diagnostic means. A diagnostic means may be any means that allows measurement of the level, amount, or concentration of the substance of interest, particularly the peptide or polypeptide of interest, and more particularly heart hormone.

Methods and diagnostic means that can be used to measure the respective peptide levels are known to those skilled in the art. These methods include microplate ELISA based methods, fully automated or robotic immunoassays (eg, Elecsys ^™ analyzer available), CBA (enzyme cobalt binding assay, eg, Roche-Hitachi ^™ analyzer) ), And latex agglutination assays (eg, Roche-Hitachi ^™ analyzer available).

  Furthermore, those skilled in the art are familiar with various methods for measuring the level of a peptide or polypeptide. The term “level” relates to the amount or concentration of a peptide or polypeptide in the patient's body (more specifically, the patient's blood or urine sample) or a sample taken from the patient (eg, a blood or urine sample). The term “measurement” according to the invention relates to determining the amount or concentration of a nucleic acid, peptide, polypeptide or other substance of interest, preferably semi-quantitatively or quantitatively. Measurements can be made either directly or indirectly. Indirect measurements include measurement of cellular responses, bound ligands, labels, or enzymatic reaction products.

  In the context of the present invention, the amount also relates to the concentration. It is obvious that the concentration of the target substance can be calculated from the total amount of the target substance in a sample of a known size, and vice versa.

  The measurement can be performed by any method known in the art. A preferred method is described below.

  In one embodiment, the method of measuring the level of a peptide or polypeptide of interest, in particular heart hormone, comprises: (a) activating a cell capable of making a cellular response to the peptide or polypeptide for a suitable time; Contacting with the peptide; and (b) measuring the cellular response.

  In another embodiment, a method for measuring the level of a peptide or polypeptide of interest, in particular heart hormone, comprises the steps of (a) contacting the peptide or polypeptide with a suitable substrate for a sufficient time; ) Measuring the amount of product.

  In another embodiment, a method of measuring the level of a peptide or polypeptide of interest, in particular heart hormone, comprises the steps of (a) contacting the peptide or polypeptide with a specific binding ligand, and (b) (optionally ) Removing unbound ligand; and (c) measuring the amount of bound ligand.

  The peptide or polypeptide is preferably contained in a sample, particularly a body fluid or tissue sample, and the amount of the peptide or polypeptide in the sample is measured.

  Peptides and polypeptides (proteins) can be measured in tissue, cell, and body fluid samples, ie preferably in vitro. The peptide or polypeptide of interest is preferably measured in a body fluid sample.

  In the present invention, a tissue sample refers to any kind of tissue obtained from a human or animal cadaver or living body. The tissue sample can be obtained by any method known to those skilled in the art, for example by biopsy or curettage.

  In the present invention, the body fluid may include blood, serum, plasma, lymph, brain fluid, saliva, and urine. Specifically, body fluids include blood, serum, plasma, and urine. The bodily fluid sample can be obtained by any method known in the art.

  Methods for obtaining cell samples include direct preparation of single cells or small cell populations, tissue dissociation (eg, using trypsin), and separation of cells from body fluids, eg, by filtration or centrifugation. . Cells according to the invention also include platelets and other non-nuclear cells such as erythrocytes.

  If necessary, the sample may be further processed. Specifically, the nucleic acid, peptide, or polypeptide may be purified from the sample according to methods known in the art, including filtration, centrifugation, or extraction methods such as chloroform / phenol extraction.

  To measure the cellular response, a sample or treated sample is added to the cell culture and the response inside and outside the cell is measured. Cellular responses include the expression of reporter genes or the secretion of substances such as peptides, polypeptides, or small molecules.

  Other methods suitable for measurement may include measuring the amount of ligand binding specific for the peptide or polypeptide of interest. The bonds according to the present invention include both covalent and non-covalent bonds.

  In the present invention, the ligand can be any peptide, polypeptide, nucleic acid, or other substance that binds to the peptide or polypeptide of interest. It is well known that peptides or polypeptides can be modified when collected or purified from the human or animal body, for example by glycosylation. Suitable ligands according to the present invention may be those that bind to peptides or polypeptides via such sites.

  The ligand should preferably bind specifically to the peptide or polypeptide to be measured. “Specific binding” according to the present invention means that the ligand should not substantially bind (“cross-react with”) another peptide, polypeptide or substance present in the sample to be tested. . The protein or isoform that specifically binds preferably has at least a 3-fold higher affinity, more preferably at least a 10-fold higher affinity, and even more preferably at least at least than any other suitable peptide or polypeptide. It should bind with 50 times more affinity.

  If the peptide or polypeptide to be tested is identifiable and can be clearly measured, for example by size on a Western blot or by its relative abundance in the sample, non-specific binding is also acceptable May be.

  Ligand binding can be measured by any method known in the art. This method is preferably semi-quantitative or quantitative. A suitable method is described below.

  First, ligand binding can be measured directly by, for example, NMR or surface plasmon resonance.

  Second, when the ligand functions as a substrate for enzyme activity of the peptide or polypeptide of interest, the enzyme reaction product can be measured (eg, the amount of protease is the amount of cleaved substrate, For example, it can be measured by measuring by Western blot).

  In order to measure the enzyme reaction product, the amount of the substrate is preferably close to saturation. The substrate may be labeled with a detectable label prior to the reaction. The sample is preferably contacted with the substrate for an appropriate time. Appropriate time refers to the time required to produce a detectable and preferably measurable amount of product. Instead of measuring the amount of product, the time required for a given (eg detectable) amount of product to occur can be measured.

  Third, the ligand can be bound covalently or non-covalently with a label that allows detection and measurement of the ligand.

  The labeling may be performed by a direct method or an indirect method. A direct label is one in which the label is bound directly (covalently or non-covalently) to the ligand. An indirect label is one that binds a secondary ligand to the primary ligand (either covalently or non-covalently). The secondary ligand is one that should specifically bind to the primary ligand. The secondary ligand may be coupled with a suitable label and / or a tertiary ligand target (receptor) that binds to the secondary ligand. Secondary, tertiary or even higher order ligands are often used to enhance the signal. Suitable secondary and higher order ligands can include antibodies, secondary antibodies, and the well-known streptavidin biotin system (Vector Laboratories).

  The ligand or substrate may be “tag labeled” with one or more tags known in the art. Such tags can then be targets for higher order ligands. Suitable tags include biotin, digoxigenin, His tag, glutathione S transferase, FLAG, GFP, myc tag, influenza A virus hemagglutinin (HA), maltose binding protein, and the like. In the case of a peptide or polypeptide, the tag is preferably at the N-terminus and / or C-terminus.

  Any label that can be detected by a suitable detection method is a suitable label. Typical labels include gold particles, latex beads, acridan esters, luminol, ruthenium, enzymatically active labels, radioactive labels, magnetic labels (eg, “magnetic beads” including paramagnetic and superparamagnetic labels) , And fluorescent labels.

Enzymatically active labels include, for example, horseradish peroxidase, alkaline phosphatase, β-galactosidase, luciferase, and derivatives thereof. Suitable substrates for detection include diaminobenzidine (DAB), 3,3′-5,5′-tetramethylbenzidine, NBT-BCIP (4-nitroblue tetrazolium chloride and 5-bromo-4-chloro-3 -Indolyl-phosphate, available as ready-made stock from Roche Diagnostics), CDP-Star ^™ (Amersham Biosciences), and ECF ^™ (Amersham Biosciences). Appropriate enzyme and substrate combinations can result in colored reaction products, fluorescence, or chemiluminescence, which can be measured by methods known in the art (eg, photosensitive film or Using a suitable camera system). With respect to measuring enzymatic reactions, the above criteria apply as well.

  Typical fluorescent labels include fluorescent proteins (such as GFP and its derivatives), Cy3, Cy5, Texas Red, fluorescein, and Alexia dyes (eg Alexia 568). Other fluorescent labels can be purchased from, for example, Molecular Probes (Oregon). The use of quantum dots as fluorescent labels is also considered.

Typical radioactive labels include ³⁵ S, ¹²⁵ I, ³² P, ³³ P, and the like. The radioactive label can be detected by any known and appropriate method, such as a photosensitive film or a phosphor imager.

  Suitable measurement methods in the present invention include precipitation (particularly immunoprecipitation reaction), electrochemiluminescence method (electrically generated chemiluminescence), RIA (radioimmunoassay), ELISA (enzyme-linked immunosorbent assay), sandwich enzyme. Immunoassay, electrochemiluminescence sandwich immunoassay (ECLIA), dissociation enhanced lanthanide fluorescence immunoassay (DELFIA), scintillation proximity assay (SPA), turbidimetry, nephelometry, latex enhanced nephelometry or nephelometry, or Phase immunity tests are also included. Other methods known in the art (gel electrophoresis, two-dimensional gel electrophoresis, SDS polyacrylamide gel electrophoresis (SDS-PAGE), western blotting, mass spectrometry, etc.) can be used alone or as described above. It can also be used in combination with labeling methods or other detection methods.

  Preferred ligands include antibodies, nucleic acids, peptides or polypeptides, and aptamers such as nucleic acid aptamers or peptide aptamers. Methods for such ligands are well known in the art. For example, identification and production of suitable antibodies or aptamers is provided by the supplier. Those skilled in the art are familiar with methods for developing derivatives of such ligands with higher affinity and specificity. For example, random mutations can be introduced into nucleic acids, peptides, or polypeptides. These derivatives can then be tested for binding by screening methods known in the art, such as phage display.

As used herein, the term “antibody” includes both polyclonal and monoclonal antibodies and fragments thereof that are capable of binding to an antigen or hapten, such as Fv, Fab, and F (ab) ₂ fragments. The present invention also includes “humanized” hybrid antibodies, in which the amino acid sequence of a non-human donor antibody exhibiting the desired antigen specificity is linked to the sequence of a human acceptor antibody. The donor sequence usually includes at least the antigen-binding amino acid residues of the donor, but can also include other amino acid residues of the donor antibody that are structurally and / or functionally appropriate. Such hybrids can be prepared in several ways well known in the art.

  In another preferred embodiment, the ligand is preferably selected from the group consisting of nucleic acids, peptides, and polypeptides, more preferably from the group consisting of nucleic acids, antibodies, and aptamers and presented on the array.

  The array contains at least one additional ligand, which may be a ligand for the peptide, polypeptide or nucleic acid of interest. The additional ligand may be a ligand for a peptide, polypeptide, or nucleic acid of no particular interest with respect to the present invention. It is preferred that the array contains ligands for at least 3, preferably at least 5, more preferably at least 8 peptides or polypeptides of interest in the context of the present invention.

  According to the present invention, the term “array” refers to a solid or gel-like support on which at least two compounds are attached or bound in a one-dimensional, two-dimensional or three-dimensional arrangement. Such arrays (including “gene chips”, “protein chips”, antibody arrays, etc.) are known to those skilled in the art and are usually coated on microscope glass slides, especially with polycations, nitrocellulose, or biotin. On coated glass slides such as coated glass slides, on cover glasses, and on membranes such as membranes based on nitrocellulose or nylon, for example.

  The array may comprise at least two cells that each express a binding ligand, or at least one ligand.

  In the present invention, it is also considered to use a “suspension array” as an array (Nolan JP, Sklar LA, (2002), Suspension array technology: evolution of the flat-array paradigm, Trends Biotechnol, 20 (1). : 9-12). In such suspension arrays, a carrier (eg, microbeads or microspheres) is present in the suspension. The array consists of various microbeads or microspheres that carry various ligands and are optionally labeled.

  The invention further relates to a method of generating an array as defined above, wherein at least one ligand binds to a carrier material in addition to other ligands.

  Methods for producing such arrays, such as those based on solid phase chemistry and photosensitive protecting groups, are known (US Pat. No. 5,744,305). Such arrays can be contacted with substances or substance libraries and tested for the presence of interactions, eg binding or conformational changes. Thus, an array comprising a peptide or polypeptide as defined above may be used to identify ligands that specifically bind to the peptide or polypeptide.

  Furthermore, it is intended to use so-called point-of-care or lab-on-a-chip devices for obtaining samples and for marker measurements. The Such a device can be designed similarly to the device used for blood glucose measurement. Thus, the patient can take a sample or measure a marker without the need of direct assistance from an experienced doctor or nurse.

  Suitable means (antibodies, aptamers, antisense nucleic acids, etc.) for measuring the expression level of the markers according to the invention have already been described in detail herein. In a preferred embodiment, these means are as a kit comprising a means for measurement or a container for a drug and a container for any auxiliary for measurement (eg suitable buffer, filter paper, enzyme, etc.). It is packed.

  In another preferred embodiment, such means are intended to be a lab-on-chip device or other device suitable for point-of-care diagnostics. Point-of-care diagnostic devices are known in the art. Presumably such a device comprises a sampling unit (eg for blood sampling) and a measurement unit (eg a unit for measuring the binding of a marker to a ligand). Further, such means may be a test paper or other auxiliary tool for measuring the expression level of the marker in the apparatus as described above.

  Accordingly, in another embodiment, the present invention also relates to a kit, a lab-on-chip device, or a point-of-care diagnostic device for measuring the expression level of a marker.

  The method according to the present invention comprises diagnosing the patient's risk by comparing the measured level to a known level associated with various degrees of risk for the patient.

  One skilled in the art can determine known levels of cardiac hormones associated with varying degrees of cardiovascular risk by administration of anti-inflammatory agents, particularly NSAIDs, steroids, or selective Cox-2 inhibitors. In general, the higher the level of heart hormone, the higher the risk for the patient.

  According to the present invention, the term “risk” relates to the probability of a particular event, more particularly a cardiovascular complication. The degree of risk can be high risk or very high risk. The degree of risk may not be high. “Not at high risk” means that there is no apparent risk of vascular events due to anti-inflammatory agents, particularly NSAIDs, steroids, or selective Cox-2 inhibitors.

  As to what level of heart hormone is associated with how much risk, guidance can be derived from heart hormone levels that are known to be associated with the presence or severity of cardiovascular disease. For example, 125 pg / ml was considered normal for plasma levels of NT-proBNP based on the 97.5 percentile obtained in individuals under the age of 50 (more specifically, NT-proBNP plasma levels of 100 pg / ml for men and 150 pg / ml for women can be considered normal levels). Higher levels of NT-proBNP correlate with, for example, symptom levels according to the NYHA classification and dysfunction levels in LVEF. The term “plasma level” relates to the level of NT-proBNP measured in plasma. Levels measured in plasma are generally comparable to those measured in serum.

  In another example, NT-proBNP plasma levels are less than 84 pg / ml in men and 155 in women based on the 97.5 percentile obtained in clearly healthy individuals under 65 years of age. If it is less than pg / ml, this can be considered a level that does not indicate a high risk. In patients complaining of dyspnea, levels below 100 pg / ml for men and below 150 pg / ml for women can be considered exclusion criteria for heart failure or ventricular dysfunction. Higher levels of NT-proBNP correlate with symptom levels according to the NYHA classification and dysfunction levels in LVEF. The term “plasma level” relates to the level of NT-proBNP measured in plasma. Furthermore, the levels measured in plasma and serum are generally comparable.

  In the following, plasma levels of NT-proBNP are presented, which usually showed cardiovascular risk from the administration of anti-inflammatory agents, Cox-2 inhibitory compounds, especially NSAIDs, steroids, or selective Cox-2 inhibitors It seems to be related to the degree.

  It is clear that the levels presented below serve only as a first category for patient risk. One skilled in the art can determine other suitable levels from the following literature: for example, Wang, TJ, Larson, MG, Levy, D. et al. (2004) Plasma natriuretic peptides and the risk of cardiovascular events and death. N Engl J Med, vol. 350, pp. 655-63; Olson, MH, Wachtell, K. Tuxen, C., Fossum, E. et al. (2004) N-terminal pro-brain natriuretic peptide predicts cardiovascular events in patients with hypertension and left hypertrophy: a LIFE study. J Hypertens, vol. 22, pp. 1597-1604) or from other clinical studies.

  Typically, plasma levels of NT-proBNP of less than 125 pg / ml are not at high cardiovascular risk from the administration of anti-inflammatory agents, Cox-2 inhibitors, especially NSAIDs, steroids, or selective Cox-2 inhibitors Associated with

  Typically, plasma levels of NT-proBNP between 125 and 500 pg / ml are associated with high cardiovascular risk from administration of anti-inflammatory agents, Cox-2 inhibitors, especially NSAIDs, steroids, or selective Cox-2 inhibitors It is done. However, levels of 80-125 pg / ml also warrant further classification of whether a high risk exists.

Typically, plasma levels of NT-proBNP above 500 pg / ml are associated with very high cardiovascular risks from administration of anti-inflammatory agents, Cox-2 inhibitors, especially NSAIDs, steroids, or selective Cox-2 inhibitors. Associated. However, levels above 400 pg / ml also warrant further classification of whether there is a very high risk.
Once a patient's risk is diagnosed, it can affect subsequent treatments, as described below. (A non-limiting example of such treatment decisions is shown in FIG. 1). The risk levels below refer specifically to the risk levels associated with the above-mentioned NT-proBNP levels.

  If the method according to the invention does not show a high risk, an anti-inflammatory agent may be administered, preferably taking into account other known risk factors for cardiovascular diseases. Preferably, administration of the drug is accompanied by further monitoring of cardiac hormone levels, especially when the drug is used at high doses or for long periods of time. As such, it can detect early abnormal increases in cardiac hormone levels that indicate increased cardiovascular risk.

  When the method according to the present invention shows a high risk, it is preferable to examine the patient more intensively by another diagnosis by a method known to a skilled cardiologist such as an electrocardiogram recording method and an echocardiography method. . Treatment with anti-inflammatory agents, especially selective Cox-2 inhibitors, should be started after careful consideration of risks and promising effects. Clearly, the present invention not only helps to safely administer anti-inflammatory agents by identifying patients at risk, but also reveals the cardiovascular risks that the patient has never noticed before. Useful. Thus, patients with high or very high cardiovascular risk are preferably subjected to further diagnosis to identify cardiovascular underlying diseases. Thereby, treatment can be started early, that is, before a clear symptom of cardiovascular disorder develops. By diagnosing cardiovascular risk before or during administration of an anti-inflammatory agent, the overall health of the patient benefits from the method of the present invention. Further, if the treatment of the underlying cardiovascular disease is good, the risk may be reduced (when diagnosed by the means and methods provided by the present invention) and anti-inflammatory agents, particularly NSAIDs, steroids, or selective Cox Treatment with -2 inhibitors can be initiated, or the dose of these drugs can be increased.

  Treatment of patients at high risk can be done with additional measures. Such means include limiting or reducing the dose of anti-inflammatory agent being administered or just about to be administered, limiting salt intake, regular and moderate exercise, immunization against influenza and pneumococci , Surgical treatment (eg, revascularization, balloon dilation, stent / graft placement, bypass surgery), diuretic (including combined administration of multiple diuretics), ACE (angiotensin converting enzyme) inhibitor, β -Administration of drugs such as adrenergic blockers, aldosterone antagonists, calcium antagonists (eg, calcium channel blockers), angiotensin receptor blockers, digitalis, and any other treatment known and considered appropriate to those skilled in the art.

  The present invention also includes a method for monitoring treatment with Cox-2 inhibitory compounds, particularly NSAIDs, steroids, or selective Cox-2 inhibitors, wherein such methods include the levels of cardiac hormones, particularly NT-proBNP. Measure the level.

  Given the risks and expected benefits, if treatment with a Cox-2 inhibitory compound, particularly an NSAID, steroid, or selective Cox-2 inhibitor is initiated, it may be an intermittent treatment. Next, by measuring natriuretic peptide, it is possible to monitor treatment, particularly intermittent treatment, and / or to identify an increased risk. Administration may be discontinued when the level of heart hormone reaches a certain value, and administration may optionally be resumed when the level of heart hormone falls below a certain value. Each value of heart hormone is as described above. For example, a value indicating discontinuation of administration can usually be a value that indicates a very high risk (as described elsewhere herein). And in some cases, the value indicating resumption of treatment may simply be a value that indicates a high risk (as described elsewhere herein) or a value that does not indicate a high risk (as described elsewhere herein).

  In view of the foregoing, the present invention further provides a method for monitoring patients who are undergoing or are about to receive treatment with Cox-2 inhibitory compounds, particularly NSAIDs, steroids, or selective Cox-2 inhibitors. It is clear to provide.

  If the method according to the invention shows a very high risk, the treatment may be adjusted as described for high risk. However, administration of Cox-2 inhibitory compounds, particularly NSAIDs, steroids, or selective Cox-2 inhibitors is not a treatment option for patients at very high risk. Whatever the reason, when administering Cox-2 inhibitory compounds, especially NSAIDs, or steroids, and more particularly selective Cox-2 inhibitors, careful medical monitoring (especially natriuretic peptides at short intervals) Monitoring, including measuring) and should monitor risk and / or identify increased risk.

  Further embodiments of the invention will be apparent from the embodiments listed below. However, in any case, it is not limited by them.

1. A method for diagnosing the risk of a patient suffering from cardiovascular complications from the administration of a Cox-2 inhibitor compound comprising the following steps:
a) measuring cardiac hormone levels; and
b) diagnosing the patient's risk by comparing the measured level with known levels associated with various degrees of risk of the patient;
Including the above method.

2. A method for diagnosing cardiovascular risk in a patient to whom a Cox-2 inhibitor compound is administered, comprising the following steps:
a) measuring cardiac hormone levels; and
b) diagnosing the patient's risk by comparing the measured level with known levels associated with various degrees of risk of the patient;
Including the above method.

3. The method of 1 or 2, wherein the heart hormone is a natriuretic peptide.

4. The method of 2, wherein the heart hormone is an ANP-type peptide or a variant thereof and / or a BNP-type peptide or a variant thereof.

5. The method of 3, wherein the heart hormone is a BNP-type peptide derived from BNP and NT-proBNP and variants thereof.

6. The method of any of 1-5, wherein the Cox-2 inhibitory compound is a selective Cox-2 inhibitor.

7. The method of any of 1-6, wherein the cardiac hormone is NT-proBNP and plasma levels of NT-proBNP of less than 80 pg / ml are not associated with a high risk of suffering from cardiovascular complications.

8. The method of 7, wherein the plasma level is less than 125 pg / ml.

9. The method of any of 1-6, wherein plasma levels of NT-proBNP greater than 125 and less than 500 pg / ml are associated with an increased risk of suffering from cardiovascular complications.

10. The method of any of 1-6, wherein plasma levels of NT-proBNP greater than 500 pg / ml are associated with an increased risk of suffering from cardiovascular complications.

11. Any of 1-10, performed under the supervision of treatment with a selective Cox-2 inhibitor.

12. Eleven methods for monitoring intermittent treatment with selective Cox-2 inhibitors.

13. Twelve methods, wherein if the level of heart hormone reaches a certain value, the administration is discontinued and if the level is below a certain value, the administration may optionally be resumed.

14. The method of any of 1-13, wherein the Cox-2 inhibitory compound is selected from the group consisting of celecoxib, rofecoxib, etlicoxib, valdecoxib, parecoxib and luminacoxib.

15. Below:
a) inflammation markers;
b) Endothelial function marker;
c) ischemic marker;
d) a platelet activation marker;
e) an atherosclerosis activation marker; and
f) an activation marker for intravascular coagulation,
The method of any of 1-14, further measuring the level of at least one marker selected from the group consisting of:

16. The risk of cardiovascular complications diagnosed is coronary heart disease, stable angina, acute coronary syndrome, unstable angina, myocardial infarction, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction or 1-15 methods with a stroke.

17. The method of any of 1-16, wherein the level of heart hormone is measured in a urine, blood, plasma or serum sample.

18. A method for determining a feasible treatment of a patient with a compound having Cox-2 inhibitory properties, the method comprising the following steps:
a) measuring cardiac hormone levels in the patient, preferably in vitro;
b) comparing the measured level with known levels associated with various degrees of risk of the patient;
c) optionally initiating examination of the patient by a cardiologist; and
d) optionally initiating or stopping treatment, taking into account the patient's test results by a cardiologist,
Including the above method.

19. A method for determining or recommending whether to treat a patient with a compound having Cox-2 inhibitory properties, the method comprising the following steps:
a) measuring cardiac hormone levels in the patient, preferably in vitro;
b) diagnosing the patient's risk by comparing the measured level with a known level associated with various degrees of patient risk;
c) Here, in some cases, taking into account the patient's test results by the cardiologist,
ca) recommending initiation of treatment if diagnosed as not at increased risk, and / or
cb) recommending discontinuation of treatment if diagnosed at high or very high risk, steps,
Including the above method.

20. Use of a diagnostic means capable of measuring a patient's heart hormone level, preferably natriuretic peptide, in any of 1-18, to measure heart hormone level or natriuretic peptide.
21. To diagnose the cardiovascular risk of a patient receiving a selective Cox-2 inhibitor or to monitor the cardiovascular risk of a patient being treated with a selective Cox-2 inhibitor, Use of a diagnostic means capable of measuring a patient's heart hormone level, preferably natriuretic peptide, wherein said heart hormone level is measured in a body fluid or tissue sample of the patient.

22. Use of 20 or 21, wherein the heart hormone is a natriuretic peptide.

23. The use of any of 20-22, wherein the level of heart hormone is measured using a specifically binding ligand, array, microfluidic device, chemiluminescence analyzer or robotic device.

24. Use of 23, wherein the specifically binding ligand is an antibody or aptamer.

  The following examples illustrate the present invention and are not intended to limit the scope of the invention in any way.

Example 1
NT-proBNP measurement
NT-proBNP can be measured by an electrochemiluminescence immunoassay using Elecsys 2010 (ElecsysproBNP sandwich immunoassay; Roche Diagnostics, Mannheim, Germany). This assay works according to the principle of an electrochemiluminescent sandwich immunoassay. In the first step, a biotin-labeled IgG (1-21) capture antibody, ruthenium-labeled F (ab ′) ₂ (39-50) signal antibody, and 20 μl of sample were incubated at 37 ° C. for 9 minutes. . Thereafter, magnetic microparticles coated with streptavidin were added and the mixture was incubated for an additional 9 minutes. After the second incubation, the reaction mixture was transferred to the measuring cell of the instrument. The beads are then trapped on the surface of the electrode by magnetic force. Unbound label was removed by washing the measuring cell with buffer.

In the final step, a voltage was applied to the electrode in the presence of a buffer containing tripropylamine, and the resulting electrochemiluminescence signal was recorded with a photomultiplier tube. All reagents and samples were operated fully automatically by the Elecsys ^™ instrument. The results were determined using a calibration curve generated specifically for the instrument with a two-point calibration and a master curve obtained with the reagent barcode. The test was performed according to the manufacturer's instructions.

  Blood for hormone analysis can be collected in EDTA tubes and lithium heparin tubes (for clinical chemistry) containing 5000 U aprotinine (Trasylol, Bayer, Germany) as needed. Blood and urine samples were immediately centrifuged at 3400 rpm at 4 ° C. for 10 minutes. The supernatant was stored at −80 ° C. until analysis.

NT-proANP measurement:
NT-proANP is based on a modified method of Sundsfjord, JA, Thibault, G. et al. (1988), Idenfication and plasma concentrations of the N-terminal fragment of proatrial natriuretic factor in man, J Clin Endocrinol Metab 66: 605-10. In a competitive binding radioimmunoassay using phase technology, the same rabbit anti-rat proANP polyclonal serum and human proANP (1-30) from Peninsula Lab (Bacherm, St. Helene, UK) as standard and radiolabeled And iodinated proANP 1-30 purified by HPLC. In order to achieve high sensitivity and good accuracy, Dynabeads M280 with sheep anti-rabbit IgG (Dynal Biotech, Oslo, Norway) was used as the solid phase and a secondary antibody was used.

Example 2
A 70-year-old elderly patient suffered from severe rheumatoid arthritis and was treated with ibuprofen for a long time. During ibuprofen treatment, he suffered from gastrointestinal side effects including gastrointestinal bleeding. The doctor decided to change treatment to use selective Cox-2 inhibitors and measured NT-proBNP. The NT-proBNP level was 223 pg / ml. The patient consulted a cardiologist for diagnosis. With echocardiograms, cardiologists diagnosed the risk of ischemic dysfunction and treatment with selective Cox-2 inhibitors. Because cardiac dysfunction is not severe, intermittent treatment with selective Cox-2 inhibitors was initiated under close monitoring of NT-proBNP.

Example 3
A 55-year-old elderly female patient had been treated with type II diabetes for 6 years and suffered from rheumatic diseases with chronic pain. Therefore her doctors considered treatment with Cox-2 inhibitors. The NT-proBNP value was measured and determined to be 647 pg / ml. The patient consulted a cardiologist for further diagnosis. Treatment with Cox-2 inhibitors did not begin due to high NT-proBNP levels and comorbidities of diabetes.

Example 4
A 72-year-old elderly patient who is healthy and smoker, but who does not have the traditional risk factors for heart disease, had extreme knee pain (probably long-term) Sports activities). The patient knew that his stomach was very sensitive. Therefore, treatment with selective Cox-2 inhibitors was investigated. The measured value of plasma NT-proBNP was determined to be 65 pg / ml. Treatment with a selective Cox-2 inhibitor was initiated because the PROCAM score was less than 40 and smoking was the only traditional risk factor.

Example 5
Use of NT-proBNP to assess the risk of suffering cardiovascular complications from the administration of anti-inflammatory agents.

  Importantly, in this example, the term “Cox-2 inhibitor” should be understood as referring to a “selective Cox-2 inhibitor”. Furthermore, in this example, the term “NSAID” refers to an NSAID that is not a selective Cox-2 inhibitor.

  NT-proBNP was measured in baseline serum samples from 433 patients participating in the prospective study. Such studies were designed primarily to clarify the therapeutic effects of novel metalloproteinase inhibitors in osteoarthritis (OA). Cardiovascular adverse events (CV-AEs) were monitored and related to the combined use of Cox-2 inhibitors or NSAIDs or prostaglandin metabolic effects steroids. In a retrospective analysis, we investigated whether the CV AE of patients receiving anti-inflammatory agents could be predicted from elevated NT-proBNP values.

  This study was originally conducted in a 24-week study to determine the dose of the MMP inhibitor Ro 113-0830 (which is extended to 30 months) for patients with early knee osteoarthritis or hand osteoarthritis. Designed by Hoffmann-La Roche Inc., Basel, Switzerland to investigate the effects of novel matrix metalloprotease (MMP) inhibitors on the progression of early osteoarthritis (OA) in patients without. Diagnosis of OA is based on clinical and radiological criteria. Second factor of OA (eg, inflammatory arthritis, congenital dysplasia and malformation, metabolic and crystal disease, neuropathy, osteonecrosis, previous fracture of the bone, Paget's disease of bone, tissue browning, acromegaly, hemochromatosis Patients with Wilson disease, gout, early osteochondromatosis) were not included. Other exclusion criteria include highly active gastrointestinal disease lesions (eg, erosions, ulcers, bleeding) or kidney disease lesions (eg, increased creatinine> 2.0 mg / dl within one year from the date of the screening visit. History of kidney dysfunction). The study was based on a double-blind, randomized, 5 ‡ -treatment group, placebo-controlled, parallel group, multicentric design and a 24-week dose-finding study. At the end of the double blind, the patient may have the option to continue for an extended period of 30 months with Ro 113-0830 treatment. All patients received informed consent. Rescue analgesics (ie, analgesics deemed necessary by the attending physician) and anti-inflammatory drugs (including Cox-2 inhibitors, NSAIDs or steroids) are approved as combination therapy and used as needed by the patient be able to.

  Rescue anti-inflammatory drugs (including Cox-2 inhibitors and NSAIDs or steroids) approved in this study include aspirin, diclofenac sodium, diflunisal, etodolac, fenoprofen, ibuprofen, ketoprofen, naproxen, nabumetone, oxaprozin, piroxicam, Sodium salicylate, magnesium choline salicylate, celecoxib, rofecoxib or tolmetin. All study cohorts were conducted after the onset of CV-AE (cardiovascular adverse events). Patients are not actively asked about the onset of angina, signs or symptoms of congestive heart failure, and arterial hypertension, and regularly check the ECG for the development of new Q waves and new leg blocks It will never be done. All CV-AEs were retrospectively categorized into different categories by expert external research surveillance.

  All CV-AEs were examined by two cardiologists. The two were not primarily involved in the study and were not shown biomarker results. Clear or potential preliminary CV adverse events include acute myocardial infarction, new Q wave or leg block, death from myocardial infarction or other cardiovascular causes, non-fatal stroke, development of edema or existing leg Onset or worsening of heart failure indicated by worsening edema of the lung, pulmonary congestion confirmed by rales or fluoroscopy on auscultation, new onset of arterial hypertension or deterioration of existing arterial hypertension, and confirmed venous thrombosis Records included. Other ECG signs, unilateral edema or isolated edema of the upper limbs were not considered preliminary events.

  On each collection day, two 10 mL venous blood samples were collected in untreated glass tubes, centrifuged, and stored in polystyrene shelves at -70 ° C or lower. Samples were sent regularly from the research center to the Central Sample Office. NT-proBNP was measured on a fully automated analyzer using a commercially available sandwich immunoassay (ELECSYS proBNP, Roche Diagnostics, Mannheim, Germany).

A total of 433 patients with OA participated and received placebo or study drug at an incremental dose of 10-150 mg. Patients were divided into the following groups according to their co-drug:
Cox-2 inhibitor group:
Of the 55 patients treated with Cox-2 inhibitors, 11 patients also received NSAIDs, 10 patients also received steroids, and 9 patients also received NSAIDs and steroids.

NSAIDs:
Of the 157 patients treated with NSAID, 39 patients also received steroids.

Steroid group:
41 patients treated with steroids only.

Comparison group:
180 patients not treated with anti-inflammatory drugs (Cox-2 inhibitors, NSAIDs and steroids). Alternative treatment with analgesics is possible.

  The basic characteristics of all four groups were similar (Table 1). Patients received placebo or study drug in 10-150 mg incremental doses. The proportion of patients receiving co-drug with Cox-2 inhibitors, NSAIDs, or steroids was equally distributed across all doses of study drug. All patient groups were comparable with respect to basic cardiovascular criteria (eg, previous cardiological disease, ECG criteria, hypertension or diabetes). As shown in Table 2, the distribution of NT-proBNP reference values is similar in the co-drug group and patients with NT-proBNP values below or above the cutoff value of 125 pg / ml and 100 pg / ml The number was also similar.

  A total of 82 mild to severe CV-AEs were recorded during the 24 week observation. The relative incidence of CV AE was significantly higher in the group receiving Cox-2 inhibitors. In addition, patients who received NSAID tended to have a high incidence of CV-AE. With Cox-2 inhibitors, the risk of CV-AE was 1.78 times higher (p = 0.06). When NT-proBNP was less than 100 pg / ml, a high CV risk could not be predicted. On the other hand, the predicted risk of CV adverse events when NT-proBNP is higher than 100 pg / ml is 4.23 times higher with Cox-2 inhibitors (p = 0.002) and 1.6 times higher with NSAIDs High (p = 0.4) and 2.2 times higher with steroids (p = 0.09) (see Table 3).

CV-AE rates were adjusted for study drug, age, and presence of diabetes. The proportion of CV-AE was significantly higher in the Cox-2 inhibitor group, and the incidence of CV-AE tended to be higher in the NSAID group and steroid group. The percentage of CV-AE was plotted over time for all groups (Figure 2). The relative incidence of CV-AEs was significantly higher in the Cox-2 inhibitor group and occurred early.

Table 4 shows the results of multivariate regression analysis. Even after adjusting for age, gender, and diabetes, high NT-proBNP independently remained a precursor to adverse outcomes when patients received Cox-2 inhibitors. A similar trend was seen when NSAIDs or steroids were given as rescue drugs or concomitant drugs.

After adjusting for study drug, age, history of hypertension or diabetes, and the probable impact of anti-inflammatory co-drugs, the risk of CV-AEs is increased if the NT-proBNP exceeds 100 pg / ml with Cox-2 inhibitors In the receiving group, it was 4.3 times higher (p = 0.0045) than in the comparative group without anti-inflammatory co-drug. On the other hand, if the NT-proBNP value was less than 100 pg / ml, there was no high risk for CV-AE in patients receiving Cox-2 inhibitors.

Even after adjusting for age, gender, and diabetes, high NT-proBNP independently remained a precursor to adverse outcomes when patients received Cox-2 inhibitors. A similar trend was seen when NSAIDs or steroids were given as rescue drugs or concomitant drugs.

  These results indicate that NT-proBNP can identify subjects for the treatment at risk of CV AE in the course of or with treatment with anti-inflammatory agents. This indicates that the administration of anti-inflammatory agents is safe in patients whose NT-pro BNP values are below the cut-off level at or after baseline. Conversely, levels of NT-pro BNP above 100 ng / ml or 125 pg / ml can be associated with various CV adverse events when taking Cox-2 inhibitors or NSAIDs or steroids alone, or a combination of anti-inflammatory agents. High risk is predicted.

FIG. 1 is a flowchart illustrating an example of the present invention. Patients who are subjects for receiving anti-inflammatory agents (eg, Cox-2 inhibitors) are divided into patients who do not have symptoms of cardiovascular disease (CV) and those who have. If the measured plasma level of NT-proBNP exceeds the selected cutoff value of 125 pg / ml, the patient can see a cardiologist. If the measured level of heart hormone is less than the selected cut-off value (e.g., 125 pg / ml NT-proBNP plasma level), then the patient has a limited health check (e.g., PROCAM score or Framingham score). Established, previous medical history, blood pressure (RR), and possibly ECG). If the result of the physical examination does not indicate cardiovascular risk, an anti-inflammatory agent is administered, but the patient is monitored for cardiac hormone levels. Cardiologists play an important role in assessing all risk indicators and treatment options. FIG. 2 shows Kaplan-Meier curves for cardiovascular adverse events (CV-AE) of all patients not using the Cox-2 inhibitor group of Example 5 vs. Cox-2 inhibitor co-agent. Plotting long-term adverse cardiovascular events as Kaplan-Meier curves shows a high risk in the Cox-2 inhibitor group (ccox2 = yes). All patients who did not use Cox-2 inhibitor co-agents (ccox2 = none) showed only a slight cardiovascular risk in summary. “Censored” means that CV-AE was not seen until the end of the observation period. N, number of people; HR, risk factor; p, probability; ccox-2, combined use of Cox-2 (means combined use of drug and Cox-2 inhibitor); survival distribution function, asymptomatic survival distribution function. FIG. 3 shows adverse cardiovascular events determined by the cardiologists of the Cox-2 inhibitor group and comparative group of Example 5 with NT-proBNP of less than 100 pg / ml or NT-proBNP of more than 100 pg / ml. The Kaplan-Meier curve based on (CV-AE) is shown. In view of the finding that selective inhibition of Cox-2 presents an excessive risk for CV-AE, raw CV-AE is used with a predetermined standard by cardiologists who are not showing NT-proBNP levels. And collated. By plotting these determined CV-AEs as Kaplan-Meier curves over a long period of time, the Cox-2 inhibitor group with NT-proBNP exceeding 100 pg / ml compared to the comparison group (subject) 4.4 The risk was doubled, and the risk was 6.4 times higher than the Cox-2 inhibitor group with NT-proBNP of less than 100 pg / ml. This risk was largely limited to patients with NT-proBNP> 100 pg / ml at the start of the study or at 24-week follow-up. The risk rate on the right shows the risk rate of the compared group shown on the left (control vs. Cox-2 inhibitor group), while the risk rate shown below the figure shows the group compared to the top (NT-proBNP levels below 100 pg / ml vs. NT-proBNP levels above 100 pg / ml). AE, adverse event; n, number; HR, risk factor; p, probability; survival distribution function, asymptomatic survival distribution function. FIG. 4 shows cardiovascular (CV) as determined by the cardiologists of the Cox-2 inhibitor group and comparative group of Example 5 with NT-proBNP less than 125 pg / ml or NT-proBNP greater than 125 pg / ml. ) Show Kaplan-Meier curve based on adverse events (AE). FIG. 4 shows the same results as shown in FIG. 3 using the NT-proBNP cutoff value of 125 pg / ml. AE, adverse event; n, number; HR, risk factor; p, probability; survival distribution function, asymptomatic survival distribution function.

Claims (33)

A method of diagnosing the risk of a patient suffering from cardiovascular complications by administration of a Cox-2 inhibitor compound, comprising the following steps:
a) measuring cardiac hormone levels;
b) diagnosing the patient's risk by comparing the measured level with known levels associated with various degrees of risk of the patient;
Including the above method. The method of claim 1, wherein the risk is not due to an increase in blood volume or intravascular volume. The method according to claim 1 or 2, wherein the patient does not show clear symptoms of cardiovascular disease. The method according to any one of claims 1 to 3, wherein the heart hormone is a natriuretic peptide. The method according to any one of claims 1 to 4, wherein the heart hormone is an ANP-type peptide or a variant thereof and / or a BNP-type peptide or a variant thereof. The method according to claim 5, wherein the heart hormone is a BNP-type peptide or a variant thereof. The method according to claim 6, wherein the BNP-type peptide is BNP or NT-proBNP or a variant thereof. 8. The method of any one of claims 1-7, wherein plasma levels of NT-proBNP of less than 80 pg / ml are not associated with a high risk of suffering from cardiovascular complications. 9. The method of claim 8, wherein the plasma level is less than 125 pg / ml. 10. The method of any one of claims 1-9, wherein plasma levels of NT-proBNP greater than 125 and less than 500 pg / ml are associated with an increased risk of suffering from cardiovascular complications. 11. A method according to any one of claims 1 to 10, wherein plasma levels of NT-proBNP above 500 pg / ml are associated with a very high risk of suffering from cardiovascular complications. 12. The method of any one of claims 1-11, wherein the method is performed in the monitoring of treatment with a selective Cox-2 inhibitor. 13. The method according to claim 12, wherein the method is for monitoring intermittent therapy with a selective Cox-2 inhibitor. 14. The method of claim 13, wherein administration is discontinued when the level of cardiac hormone reaches a certain value and is optionally resumed when the level falls below a certain value. 15. The method according to any one of claims 1 to 14, wherein the coxib is selected from the group consisting of celecoxib, rofecoxib, etoroxixib, valdecoxib, parecoxib and luminacoxib. In addition:
a) Inflammatory marker
b) Endothelial function marker
c) Ischemic marker
d) Platelet activation marker
e) Atherosclerosis activation marker
The method according to any one of claims 1 to 15, wherein the level of at least one marker selected from the group consisting of f) an intravascular coagulation activation marker is measured. The cardiovascular complication is coronary heart disease, stable angina, acute coronary syndrome, unstable angina, myocardial infarction, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction or stroke. The method of any one of -16. 18. A method according to any one of claims 1 to 17, wherein the level of heart hormone is measured in a urine, blood, plasma or serum sample. 19. The method of any one of claims 1-18, wherein the level of heart hormone is measured using a specifically binding ligand, array, microfluidic device, chemiluminescence analyzer or robotic device. 20. The method according to claim 18 or 19, wherein the ligand that specifically binds is an antibody or an aptamer. A method for diagnosing cardiovascular risk in a patient to whom a selective Cox-2 inhibitor is administered, or a method for monitoring cardiovascular risk in a patient receiving treatment with a selective Cox-2 inhibitor, the patient A method as described above, wherein a body fluid or tissue sample is collected and the level of cardiac hormone is measured by a diagnostic method capable of measuring the hormone. 24. The method of claim 21, wherein the patient does not show clear symptoms of cardiovascular disease. The method according to claim 21 or 22, wherein the heart hormone is a natriuretic peptide. A method for determining whether to initiate treatment of a patient with a compound having Cox-2 inhibitory properties, comprising:
a) measuring cardiac hormone levels in the patient, preferably in vitro;
b) diagnosing the patient's risk by comparing the measured level with known levels associated with various degrees of risk of the patient;
c) In some cases, taking into account the patient's diagnosis by the cardiologist,
ca) recommending initiation of treatment if diagnosed as not at high risk, and / or
cb) recommending discontinuation of treatment if it is diagnosed at high or very high risk;
Including the above method. 24. The method of claim 23, wherein the heart hormone is NT-proBNP and the compound is a selective Cox-2 inhibitor. 25. The method of claim 24, wherein the selective Cox-2 inhibitor is selected from the group consisting of celecoxib, rofecoxib, etlicoxib, valdecoxib, parecoxib and luminacoxib. A method for diagnosing cardiovascular risk in a patient to whom a selective Cox-2 inhibitor is administered, comprising the following steps:
a) measuring heart hormone levels;
b) diagnosing the patient's risk by comparing the measured level with known levels associated with various degrees of risk of the patient;
Including the above method. 28. The method of claim 27, wherein the heart hormone is NT-proBNP. 30. The method of claim 28, wherein the method is performed in monitoring treatment with a selective Cox-2 inhibitor. A method of diagnosing the risk of a patient suffering from coronary heart disease or stroke by administration of a selective Cox-2 inhibitor, said method being performed before administering a selective Cox-2 inhibitor, comprising the following steps: :
a) measuring the level of NT-proBNP or a variant thereof in a plasma or serum sample from a patient;
b) diagnosing the patient's risk by comparing the measured level with known levels associated with various degrees of risk of the patient;
c) where the plasma or serum level of NT-proBNP is 100 pg / ml or higher, especially 125 or higher, associated with a high risk of suffering from cardiovascular complications,
Including the above method. A method for determining whether a patient can be treated with a selective Cox-2 inhibitor comprising the following steps:
a) measuring the level of NT-proBNP or a variant thereof in a plasma or serum sample from a patient;
b) determining treatment, possibly taking into account the results of examination of the patient by the cardiologist;
c) where
ca) If the measured plasma or serum level of NT-proBNP is 100 pg / ml or higher, especially 125 pg / ml or higher, it is recommended that patients not be treated or under cardiovascular monitoring And / or recommending approval of treatment with low-dose selective Cox-2 inhibitors, and / or
cb) If the measured plasma or serum level of NT-proBNP is 400 pg / ml or more, especially more than 500 pg / ml or more, recommend not to treat the patient;
Including the above method. A method for determining whether to start treatment of a patient with an anti-inflammatory agent, comprising the steps of
a) measuring the level of NT-proBNP or a variant thereof in a plasma or serum sample from a patient;
b) if NT-proBNP plasma or serum levels measured here are 100 pg / ml or higher, especially 125 pg / ml or higher, indicating that treatment should not be started;
Including the above method. 35. The method of claim 32, wherein the anti-inflammatory agent is a selective Cox-2 inhibitor.

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